report of the task group on conflict free case management conflict free case...the group will not...

Conflict Free Case Management Task Group –Report

Report of the Task Group

on Conflict Free Case Management

October 31, 2014

Submitted to:

Colorado Department of Health Care Policy & Financing

Division for Intellectual & Developmental Disabilities


Colorado Department of Health Care Policy and Financing

Division for Intellectual and Developmental Disabilities

Conflict Free Case Management Task Group

Report Draft – October 31, 2014

Background

The Division for Intellectual and Developmental Disabilities (DIDD) solicited individuals

interested in participating in a multi-stakeholder task group (Group) in December 2013. In its

notice, the DIDD indicated that the task group was being formed in response to a nationwide

system change initiated by the Federal Centers for Medicare and Medicaid Services (CMS)

proposed rule that addresses conflict of interest related to case management. The final rule was

effective March 17, 2014 and is as follows:

“Providers of HCBS for the individual, or those who have an interest in or are employed

by a provider of HCBS for the individual must not provide case management or develop

the person-centered service plan, except when the state demonstrates that the only willing

and qualified entity to provide case management and/or develop person-centered service

plans in a geographic area also provides HCBS. In these cases, the State must devise

conflict of interest protections including separation of entity and provider functions

within provider entities, which must be approved by CMS. Individuals must be provided

with a clear and accessible alternative dispute resolution process.”

The rule lists several reasons conflicts may exist, including but not limited to incentives for over-

or under-utilization of services; interest in retaining individuals as clients rather than promoting

independence; and issues where the focus is not person-centered.

In July 2012, Governor John W. Hickenlooper issued an Executive Order, creating the Office of

Community Living within the Department of Health Care Policy and Financing (Department).

This Executive Order also created the Community Living Advisory Group, which was charged

with recommending ways to reform Colorado’s Long Term Services and Supports (LTSS)

system. The Community Living Advisory Group released its final report and recommendations

in September 2014. The report has final consensus recommendations of the Community Living

Advisory Group and its five subcommittees.

Creating comprehensive access points for all LTSS is one final recommendation from the

Community Living Advisory Group. This recommendation included information that “In some

cases it may be impractical to separate the functions of eligibility determination, case

management and service provision – for example, in rural and frontier areas, where there are few

provider agencies. In those cases, the Department will need to create firewalls within agencies to

minimize conflict of interest.


“Once eligibility has been determined individuals should have the freedom to choose their case

management agency.” Once the case management agency is chosen, the recommendation also

states that this model would allow case managers to conduct quality assurance to verify that

consumers are receiving services as they expect.

Another recommendation from the Community Living Advisory Group is to tailor case

management to individual needs and preferences. Encompassed within this recommendation is a

restructuring of Colorado’s case management system so that people receiving services have as

much choice as possible in case management agencies; that the level of case management is

tailored to the individual needs and preferences of the person receiving services; and that training

is provided to case managers.

The Task Group (Group) was charged with developing recommendations for consideration by

the Department regarding a process to establish a conflict-free case management system for

persons enrolled in Home and Community Based Services (HCBS) for Persons with a

Developmental Disability (HCBS-DD), HCBS-Supported Living Services (HCBS-SLS) and

HCBS-Children’s Extensive Support (HCBS-CES).

At its first meeting on February 19, 2014, the following goals were defined for the work of the

Group:

The charge of this Group is to make recommendations for a case management model (may

have more than one) that is integrated, person-centered, transparent, and offers free choice of

case management.

The goal is to move from an agency based structure to a person-centered, conflict-free case

management structure.

The Group will not focus on the finer points of implementation, funding, Third Party

Eligibility, and will not consider details of conflict of interest.

When first convened, the charge emphasized creating a system that offers free choice of case

management. The Group’s charge expanded as a result of the release of a CMS final HCBS rule,

42 CFR § 441.301(c)(1)(vi), effective March 17, 2014. The final rule further emphasized the

need for recommendations for a case management system which separates case management

from direct service provision. As a consequence of its expanded scope, the Group’s timeframe

for producing final recommendations was extended from July 2014 to October 31 2014.


Membership

The Department sent out a Communications Brief (Brief) on December 12, 2013 inviting

individuals to serve on the Conflict Free Case Management (CFCM) Task Group. The Brief

noted that:

The Task Group will develop recommendations for consideration by the Department regarding

a process to establish a conflict-free case management system for persons enrolled in Home

and Community Based Services (HCBS) for Persons with a Developmental Disability (HCBS-

DD), HCBS-Supported Living Services (HCBS-SLS) and HCBS-Children’s Extensive Support

(HCBS-CES). The Task Group will hold six meetings between February 2014 and July 2014.

As noted above the timeframe for the Task Group was extended to October 31, 2014. The

Department reviewed the Task Group Participation Interest Form that interested individuals were

required to submit and selected sixteen members representing a spectrum of stakeholders.

Individuals were selected rather than organizations; people were not able to substitute a voting

proxy if they were not able to attend. During the nine months of the Task Group, one individual

resigned. See Appendix 1 for a complete list of members.

The Task Group was staffed by Brittani Trujillo and Lori Thompson with the DIDD. In addition,

Claire Brockbank, Segue Consulting, was contracted to facilitate the Task Group meetings as

well as provide support to the DIDD as needed to address the substantive needs of the Task

Group.


Meetings and Work Process

The Group met nine times, on:

February 19, 2014

March 18, 2014

April 15, 2014

May 20, 2014

June 23, 2014

August 20, 2014

September 9, 2014

October 8, 2014

October 22, 2014

Meetings generally were scheduled for three hours and were accessible in-person or via

teleconference. Starting with the May 20 meeting, all meetings were audiotaped, with the

complete audio file/recording available on Drop Box and will be posted to the Department’s

website. See Appendix 2 for a complete set of Meeting Summaries and attachments from public

comment.

All meetings were open to the public and guests were afforded an opportunity to provide

comment and input at the end of every meeting. To ensure responsiveness and accountability,

the Group established timeframes for setting meeting agendas, distributing meeting packets, and

completing Meeting Summaries. See Appendix 3 for the Task Group’s timeframes.

The Group’s initial focus was on educating themselves regarding models being used by other

states, a review of the Balancing Incentive Program (BIP), and gaining a better understanding of

the CMS Final Rule. As a strong foundation was established the discussions evolved to

identifying specific areas of concern and exploring possible options for consideration.

As the Group began discussing specific recommendations, it became clear that there would be

areas of consensus but also important areas where no consensus would be achieved. The Group

determined that all recommendations would be submitted to the Department, regardless of

whether consensus was achieved.


Framing the Issue

The Group agreed that any modifications to the current Targeted Case Management (TCM)

system must keep intact the four current components of TCM:

1. Comprehensive assessment and periodic reassessment of individual needs to determine

the need for any medical, educational, social, or other services and completed annually or

when the client experiences significant change in need or in level of support. These

assessment activities include:

a. taking client history

b. identifying the client’s needs, completing related documentation, and gathering

information from other sources such as family members, medical providers, social

workers, and educators as necessary, to form a complete assessment of the client

2. Development and periodic revision of a specific care plan that:

a. is based on the information collected through the assessment

b. specifies the goals and actions to address the medical, social, educational, and

other services needed by the client

c. includes activities such as ensuring the active participation of the client, and

working with the client (or the client representative) and others to develop those

goals, and

d. identifies a course of action to respond to the assessed needs of the client

3. Referral and related activities to help a client obtain needed services including activities

that help link a client with:

a. medical, social, educational providers, or

b. other programs and services including, making referrals to providers for needed

services and scheduling appointments, as needed

4. Monitoring and follow-up includes activities that are necessary to ensure the care plan is

implemented and adequately addresses the eligible individual’s needs. Monitoring and

follow up actions shall:

a. be performed when necessary to address health and safety services in the care

plan

b. include activities to ensure:

i. Services are being furnished in accordance with the client’s care plan

ii. services in the care plan are adequate, and

iii. necessary adjustments in the care plan and services arrangements with

providers are made if the needs of the client have changed

c. Include direct contact and observation with the client in a place where services

are delivered to a client in accordance with the following frequency:

i. Face to face monitoring shall be completed for a client enrolled in HCBS-

DD at least once per quarter


ii. Face to face monitoring shall be completed for a client enrolled in HCBS-

SLS at least once per quarter

iii. Face to face monitoring shall be completed for a client in HCBS-CES at

least once per quarter, or

iv. Face to face monitoring shall be completed at least once per six month

period for children in Early Intervention Services

Although there is potential for many different types of conflict of interest in Colorado’s

Intellectual and Developmental Disability (I/DD) system, the Group focused specifically on the

conflict of interest that can occur when case management and service provision are provided

within a single organization or across multiple organizations that are not entirely independent of

each other. This focus was consistent with the requirements of the new HCBS regulations.


Recommendations

Process for selecting final recommendations:

The Group developed and maintained a list of ongoing ideas for consideration. Over time, these

ideas started to coalesce around several distinct options. The Group agreed during its initial

meetings that a recommendation did not have to achieve consensus to be included in the final

report. The Group did not take votes on its recommendations; discussions made it amply clear

where there was and was not consensus. The Group felt that a vote count might over or under

emphasize the complexity of the option regarding recommendations in a misleading manner.

Consensus Recommendations

There were several areas where the Group achieved consensus. These include:

The Case Management Agency (CMA) will provide the following for all individuals

receiving services:

o Annual Assessment (as defined in the TCM rules, referenced above)

o Service Plan development

o Service Plan monitoring

The CMA will provide referral and related activities to help an individual obtain needed

services, though the family or individual may conduct these activities, without being

paid, at the discretion of the individual unless guardianship is in effect. This option will

be available when guardianship is in effect, at the discretion of the guardian.

Family-provided case management: As noted above, Service Plan implementation can be

done by the family, as mutually agreed upon and without pay, rather than the CMA.

However:

o Annual Assessment, Service Plan development and monitoring must be

completed by a CMA

The Department will need to actively support the creation of a new market sector for

independent case management services.

o A thriving and robust cadre of CMAs will provide choice of CMA and case

manager for individuals receiving I/DD services in Colorado.

Organizations providing case management services must comply with all federal

regulations regarding separation from other entities providing services.


Non-Consensus Recommendations

The Group did not achieve consensus on the following due to some fundamental differences

regarding the direction the Department should take to achieve conflict free case management.

These include:

1. The need for case management to exist, in all cases, in an agency entirely independent of an

agency providing direct service provision.

Independent Perspective: case management services should only be provided by an entity

that does not provide direct services. This is the only way to truly ensure that conflicts of

interest will not occur with respect to case management and direct services and is the

most explicit way to align with the CMS final rule.

The need for a co-existing option which allows for both case management and HCBS

direct services to be provided by the same entity.

Option 1: An agency1 may provide both case management and service delivery but not to

the same individual.

a. In this situation, the individual must decide if he/she prefers to receive case

management or service delivery from the agency; whichever is chosen, the

individual must go to another qualified agency of his/her choice for the other.

Option 2: An agency may provide both case management and service delivery to the

same individual.

a. In this situation, the individual can receive case management and service

delivery from the same agency; however, a robust informed choice process

must be in place, which allows the individual to explicitly opt out of the

CFCM protections.

2. The need for an exceptions process that anticipates the possibility of insufficient access to

independent case management services.

Exceptions: In the case where an individual may not have access to a case manager such

as rural or underserved areas, the final HCBS rule allows for the state to devise conflict

of interest protections. Any exception must be approved by CMS, per the final regulation.

No Exceptions: Allows for more Case Management Agencies to emerge, offering

maximum choice to individuals receiving services.

1 Agency is used instead of Community Centered Board or CCB to reflect the agency delivering case management

services regardless of what that agency is ultimately called. Although stakeholders currently know these agencies as

CCBs, in the future this may not be the case.


3. The need for an exemption provision

Exemption Provision: In order to accommodate Person-Centered choice and minimize

disruption, an exemption provision should be included for individuals who have a

relationship with an agency that provides both CM and direct services and who does not

want to terminate either relationship.

No Exemption Provision: In the final HCBS rule, the only exemption provision is for

rural and underserved areas where there are no other options for case management and/or

Service Plan development and direct service provision. In this case, the State must devise

conflict of interest protections.


An Overall Systems Perspective

These individual recommendations function together in three distinct options for the Department

to consider as recommendations to achieve Conflict Free Case Management. These are

represented graphically below, but each specific component is described in the recommendations

above.

Option One: Complete Separation

Agencies must decide whether to provide case management or HCBS direct services.

Targeted Case Management HCBS Direct Services

Independent case managers

Agencies that opt to provide

case management and not

provide HCBS direct services

Independent service providers

Self-directed services

Agencies that opt to be HCBS

providers and not provide CM

Pro

vide

d b

y:

Pro

vide

d b

y:


Option Two: External Separation – Internal Co-existing CM and HCBS Direct Services

Agencies may offer case management and HCBS direct services but not to the same individual.

Independent case managers

Case Management Agencies

Independent service providers


Public or private agency:

Can provide both case management and HCBS direct

services but may not provide both to the same

individual

Pro

vided

by:

Pro

vided

by:



Option Three: Person-Centered Choice Informed Consent Opt-out of Conflict Free Case

Management

Individual makes an informed consent to opt-out of separate case management and HCBS direct

services.


Agencies

Agencies


Individual receiving both CM and HCBS direct services from the

same agency must undergo an informed choice process and

explicitly opt out of CFCM

Pro

vide

d b

y:

Pro

vide

d b

y:

Agencies Providing Both Case Management and Direct Services

Age

nci

es

Pro

vid

ing

Bo

th C

ase

Man

age

me

nt

and

Dir

ect

Serv

ices

Agencies Providing Both Case Management and Direct Services


An Individual’s System Perspective

The three options presented for consideration can also be viewed from the perspective of the

individual being served by the system.

Option One: Complete Separation

No matter what course an individual receiving services takes, he/she will receive CFCM.

Individual selects independent Case

Manager:

Any qualified agency that provides

case management services

Case Manager provides:

Annual Assessment

Service Plan development

Service Plan monitoring

Family or Case Manager provides:

Referral and related activities to help an

individual obtain needed services

Individual receives HCBS direct

services:


Services provided by an agency

that does not provide case

management

Department establishes

licensure requirements,

provides oversight and serves as

a safety net or back-up case

management entity


Option Two: External Separation – Internal Co-existing of CM and HCBS Direct Services

The individual receiving services may select an agency for either case management or direct

services but not for both.

Agency that provides both case

management

and HCBS direct services

Case Management • HCBS Direct

Services

If individual receives CM from an

agency that does both, individual

must receive direct services from:

Independent service provider


Department establishes licensure

requirements, provides oversight and

serves as a safety net or back-up case

management entity

If individual receives HCBS direct

services from an agency that does

both, individual must receive case

management services from:

Separate case management

agency

Individual Selects:


Option Three: Person-Centered Choice Informed Consent Opt-out of Conflict Free Case

Management

The individual receiving services makes an informed consent to opt-out of separate case

management and direct services.

Individual wants an agency to

provide case management services

and HCBS direct services

Agency Case Manager provides

Annual Assessment

Service Plan development

Service Plan monitoring

Family or CMA provides

Referral and related activities to

help an individual obtain needed

services

Individual receives HCBS direct

services from:

Qualified HCBS service provider


Department establishes

licensure requirements,

provides oversight and serves

as a safety net or back-up case

management entity

Individual:

Participates in a robust informed

choice process and opts out of

CFCM

Individual can change his/her mind

at any point in the process


Considerations for Implementation of any Model

Regardless of the model chosen, the Group identified recommendations for quality service

delivery. Although the charge to the group was to provide recommendations to the

Department regarding options for CFCM, the Group had a deep understanding that “how”

these recommendations are implemented will be critical to the success of any effort to reduce

the opportunity for conflict of interest in a new system and to minimize unintended

consequences. As such, it maintained a list of issues and recommendations for responsible

and conscientious consideration in the move to implementation

The model will contain a process by which individuals receiving services and their

families experience continuity during transition to the new model.

All individuals enrolled in the HCBS waivers should be afforded conflict-free case

management options.

Reimbursement must be sufficient to support the commitment and expertise required to

maintain a stable case management sector.

Qualifications and Training: The Department will ensure Case Management Agencies

and Case Managers meet qualifications by successfully completing their training and on-

going training. The Department will provide training on the waiver and state plan

requirements, regulations, and administrative processes.

Transition from the current system to a new system should be conducted strategically to

ensure continuity for the individuals enrolled in the waivers.

A fiscal impact analysis should be conducted to determine the cost of the system to

change to CFCM.

A systems analysis should be conducted to determine the impact on the roles and

responsibilities of the current Community Centered Board service delivery system and the

implications on the multiple functions they perform for the state unrelated to TCM and the

individuals, families, and communities served.


Bibliography

CMS Regulations and State Regulatory & Background Material

Application for 1915(c) HCBS Waiver Appendix D: Participant-Centered Planning and

Service Delivery, July 1, 2014

Centers for Medicare and Medicaid Services, CFR-2011-Title 42-vol12-sec411-354

Financial Interest

Centers for Medicare and Medicaid Services, CFR-2011-Title 42-vol12-sec441-18 Case

Management Services

Centers for Medicare and Medicaid Services, Technical Assistance Tool Optional State

Plan Case Management, 4/18/08

Colorado Home and Community-Based Services (HCBS) Medicaid Waivers: Adult

Waivers, Updated June 2013

Department of Health and Human Services, Federal Register, January 16, 2014: HCBS

Final Rule

State Plan Under Title XIX of the Social Security Act State: Colorado

Reports and Studies

Addressing Potential Conflicts of Interest Arising from the Multiple Roles of Colorado’s

Community Centered Boards, December 2007, University of Southern Maine

Colorado Department of Human Services Division for Developmental Disabilities and

Department of Health Care Policy and Financing Long Term Benefits Division: Conflict

of Interest Task Force Report, September 15, 2010

Community Living Advisory Group Report, Final Recommendations, September 2014

Controls Over Payments Medicaid Community-Based Services for People with

Developmental Disabilities Department of Health Care Policy and Financing Department

of Human Services Performance Audit, Office of the State Auditor, June 2009

Feasibility Analysis of Community First Choice in Colorado, Mission Analytics Group,

December 2013

FY 2007 DDD TCM Satisfaction Survey, June 2007

Innovative Models and Best Practices in Case Management and Support Coordination,

University of Minnesota, April 2008

The Balancing Incentive Program: Implementation Manual, Mission Analytics Group,

October 2011

Task Group Meeting Material

Administrative Case Management (ACM) Overview, Prepared by Division for March 21,

2014 Task Group meeting

Targeted Case Management (TCM) Overview, Prepared by Division for March 21, 2014

Task Group meeting

State Models

Conflict Free Case Management State Models Spreadsheet


Arkansas: Structural Change BIP Application

Kansas Department of Health and Environment,

o Amendment to the KanCare Medicaid Section 1115 Demonstration

o Targeted Case Management Activities, Memo September 5, 2013

Massachusetts: BIP Application

New Jersey: Conflict Free Policy for The Supports Program,

Ohio: Conflict Free Case Management Strategies for Integrated and Managed Care Long-

Term Services and Supports Environment, September 5, 2013

Wyoming Best Practice CFCM Briefing, April 2013

Wyoming BHD Conflict-free Case Management Model, November 6, 2013

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